Importance of metastatic volume in prognostic models to predict survival in newly diagnosed metastatic prostate cancer.

PURPOSE: To explore the prognostic importance of metastatic volume in a contemporary daily practice cohort of patients with newly diagnosed metastatic hormone-naive prostate cancer (mHNPC) and to develop a pragmatic prognostic model to predict survival for these patients. METHODS: Since 2014, 113 patients with newly diagnosed mHNPC were prospectively registered. Statistical analysis was performed using SPSS 25.0™ with two-sided p value < 0.05 indicating statistical significance. Univariate and multivariate cox regression analyses were performed to identify prognostic risk factors. Kaplan-Meier method with log-rank statistics was constructed to analyze difference in survival in the prognostic groups. Model performance was assessed using the Concordance-index (C-index) and cross-validated in R v3.4.1. High-volume mHNPC (HVD) was defined as the presence of visceral metastasis or ≥ 4 bone metastases with ≥ 1 appendicular lesion. RESULTS: Multivariate analysis identified HVD (p = 0.047) and elevated alkaline phosphatase (ALP) (p = 0.018) as independent prognostic risk factors for overall survival (OS). Consequently, three prognostic groups were created: a good (no risk factors), intermediate (1 risk factor) and poor prognosis group (2 risk factors). Median OS for the good, intermediate and poor prognosis group was not reached, 73 and 20 months (95% CI 9-31 months with p < 0.001 and Correspondence-index of 0.78), respectively. CONCLUSIONS: We developed a pragmatic and qualitative prognostic model consisting of three prognostic risk groups for OS in a daily practice cohort of patients with newly diagnosed mHNPC. Independent prognostic risk factors included in the model were HVD and abnormal ALP.

T-staging of prostate cancer: Identification of useful signs to standardize detection of posterolateral extraprostatic extension on prostate MRI.

OBJECTIVES: To determine the prevalence and predictive value of a series of commonly used MRI criteria for posterolateral extraprostatic extension (EPE) of prostate cancer (PCa). METHODS: The presence of EPE in index lesions visible on prebiopsy mpMRI (T2w, DWI and DCE on a 3 Tesla-system) of biopsy-proven PCa patients was blindly assessed retrospectively by two radiologists with 8- and 17-years of experience on the basis of 8 commonly used staging criteria. Radical prostatectomy was used as standard of reference. The prevalences and positive predictive values (PPV) of all criteria were calculated for each reader separately and averaged for the two readers together. Cohen's K and percentage of agreement were used to assess the interobserver agreement. RESULTS: In 51 patients (mean age: 63 years; mean PSA: 17.2 ng/ml), tumor-capsule contact was the most prevalent sign (average 56,9%), but with the lowest PPV (average 51.9%), although increasing with broader capsular contact (56.5% if ≥10 mm; 87.5% if ≥20 mm; 100% if ≥25 mm). "Early signs" of EPE such as bulging, capsular disruption and unsharp prostatic margin showed a prevalence of 11.8%-18.6% on average, with 74.5%-86.3% of agreement; the average PPV range was 69.0%-75.0%. "Late signs" of EPE such as irregular prostatic contour, periprostatic fat infiltration, rectoprostatic angle obliteration and periprostatic mass showed a prevalence of 2.9%-8.8% on average, with 86.3%-94.1% of agreement; the average PPVs ranged between 85.7% and 100%. CONCLUSIONS: "Early" signs of EPE show high prevalences but low PPVs, while "late" signs show lower prevalences but higher PPVs. MRI-staging following this chronological concept can standardize morphologic staging and decrease the existing multi-reader variability.

A Systematic Review on the Role of Imaging in Early Recurrent Prostate Cancer.

CONTEXT: In patients treated for prostate cancer, a rising serum prostate-specific antigen (PSA) level is a first sign of relapse, but imaging is needed to determine the localization of the recurrence, which may be local, in lymph nodes, and/or metastatic. With the increasing success rate of earlier salvage therapy, the diagnosis has become pertinent when the recurrent PSA level is still very low. OBJECTIVE: To systematically review the literature on the role of the existing imaging techniques in patients with early recurrent prostate cancer. EVIDENCE ACQUISITION: A systematic literature search across the MEDLINE and EMBASE databases was conducted in February 2018, searching for original studies reporting on imaging in a (sub)group of patients with recurrent PSA levels not higher than 5ng/ml. This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The methodological quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. EVIDENCE SYNTHESIS: A total of 98 studies were included in this systematic review, reporting on the role of transrectal ultrasonography (TRUS), computed tomography (CT), bone scintigraphy (BS), single-photon emission CT, multiparametric magnetic resonance imaging (mpMRI), whole-body MRI (wbMRI), and positron emission tomography (PET)-CT/MRI using 18F fluoro-deoxy-glucose, 11C choline, 18F (fluoro)(methyl)choline, 11C acetate, 18F FACBC (fluciclovine) and prostate-specific membrane antigen (PSMA)-based tracers. CT and BS were not sufficiently sensitive in the early recurrence setting. For the detection of local recurrence, TRUS or mpMRI can be used; however, at the lowest PSA levels, few data were available, only after radical prostatectomy, showing a wide range of positivity. TRUS or mpMRI need to be combined with (PET)-CT to assess distant disease, but new techniques such as wbMRI, PET-MRI, or PET-CT allow for an all-in-one approach. At recurrent PSA levels <0.5ng/ml, detection rates up to 31.3% were reported using 11C choline PET-CT and up to 65.0% using 68Ga PSMA-11 PET-CT. At recurrent PSA levels <0.2ng/ml, detection rates of 68Ga PSMA-11 PET-CT ranged from 11.3% to as high as 58.3%. CONCLUSIONS: Detection rates of different imaging techniques depend on the PSA level at the time of imaging. Recent advanced imaging techniques may detect the localization of the recurrence, even when the PSA levels are still very low. PATIENT SUMMARY: In patients treated for prostate cancer, a rising serum prostate-specific antigen (PSA) level is a sign of recurrence of the disease. Advanced imaging techniques may demonstrate the localization of the recurrence, even when the PSA levels are still very low.

The prostate cancer focal therapy.

Despite prostate cancer (PCa) is the leading form of non-cutaneous cancer in men, most patients with PCa die with disease rather than of the disease. Therefore, the risk of overtreatment should be considered by clinicians who have to distinguish between patients with high risk PCa (who would benefit from radical treatment) and patients who may be managed more conservatively, such as through active surveillance or emerging focal therapy (FT). The aim of FT is to eradicate clinically significant disease while protecting key genito-urinary structures and function from injury. While effectiveness studies comparing FT with conventional care options are still lacking, the rationale supporting FT relies on evidence-based advances such as the understanding of the index lesion's central role in the natural history of the PCa and the improvement of multiparametric magnetic resonance imaging (mpMRI) in the detection and risk stratification of PCa. In this literature review, we want to highlight the rationale for FT in PCa management and the current evidence on patient eligibility. Furthermore, we summarize the best imaging modalities to localize the target lesion, describe the current FT techniques in PCa, provide an update on their oncological outcomes and highlight trends for future research.